Rev Panam Salud Publica 41, 2017 1

Hospital-based tuberculosis control activities in five cities of Latin America

Ralfh Moreno,1 Rafael López,1 Alfonso Tenorio,1 Jorge Victoria,1 Anna Volz,1 Oscar Cruz,2 Ernesto Moreno,3 Carlos Quijada,4 Ana Hesse-de-Herrera,4 Sarita Aguirre,5 Laedi Santos,6 Noemi Lima,7 Neide Tanomaru,7 Antonieta Alarcon8 and Mirtha Del-Granado1

Pan American Journal of Public HealthOriginal research

Suggested citation Moreno R, López R, Tenorio A, Victoria J, Volz A, Cruz O, et al. Hospital-based tuberculosis control activities in five cities of Latin America. Rev Panam Salud Publica. 2017;41:e95.

Despite the remarkable health prog-ress achieved by the Millennium Devel-opment Goals (1) at the global and regional levels, there remain substantial challenges for the prevention of death

and disability due to communicable dis-eases (1). As recently as 2014, an esti-mated 9.6 million people developed active tuberculosis (TB) and 1.5 million died of the disease (2).

Particularly, in Latin America and the Caribbean, TB exhibits consider-able variation. In 2013, for instance, TB incidence and mortality in Central America were 28 and 1.9 per 100 000, respectively; whereas in the Caribbean, these figures were as high as 70 and 8.3 per 100 000 (3), with some countries well above these averages (4). These areas of high burden represent a strategic priority in the TB elimination effort.

ABSTRACT Objective. To generate actionable insights for improving TB control in urban areas by describing the tuberculosis (TB) control activities of hospitals in five cities in Latin America.Methods. A descriptive study of hospital-based TB control activities was conducted in 2013–2015 using a cross-sectional survey designed by the Pan American Health Organization and administered in Guatemala City, Guatemala; Guarulhos, Brazil; Bogotá, Colombia; Lima, Peru; and Asunción, Paraguay. Data were analyzed using Chi-squared, Fisher exact tests, and the Mantel–Haenszel test for Risk Ratios, as necessary (P < 0.05).Results. While variation among cities existed, most hospitals (91.3%) conducted acid-fast bacilli smears for TB diagnosis and had a quality control process (94.0%), followed national TB guidelines (95%), and reported TB cases to the respective health authorities (96%). Additionally, TB treatment was offered free of charge almost universally (97.1%). However, only 74.2% of hospitals were supervised by the national or local TB programs; 52.8% followed up on the outcome of referrals; and 39.1% offered full ambulatory TB treatment, with 68.7% using Directly-Observed Therapy.Conclusion. The study underscored strengths and weaknesses in specific areas for TB con-trol activities in hospitals and highlighted the importance and complexity of coordinating efforts among private and public hospitals and the various stakeholders. Local TB programs and health authorities should use these results to enhance the quality of TB-related actions in hospitals in similar settings.

Keywords Tuberculosis; hospital services; cities; Brazil; Colombia; Guatemala; Paraguay; Peru; Latin America.

1 Pan American Health Organization, Washington, DC, United States of America. Send correspon-dence to Ralfh Moreno, ralfmorenog@gmail.com

2 Secretary of Health of Bogotá, Bogotá, Colombia.

3 Ministry of Health and Social Protection, Bogotá, Colombia.

4 Ministry of Public Health and Social Welfare, Guatemala City, Guatemala.

5 Ministry of Public Health and Social Welfare, Asuncion, Paraguay.

6 Center for Epidemiological Surveillance, São Paulo, Brazil.

7 Health Secretary of Guarulhos, Guarulhos, Brazil.8 Ministry of Health, Lima, Peru.

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Original research Moreno et al. • Hospital-based TB control activities in five cities

Beyond regional variations, TB is also influenced by urbanization. Cities tend to have a higher TB burden, especially in deprived areas where poverty, over-crowding, and poor sanitation are com-mon (5). At the same time, a larger concentration of high-risk populations—the homeless, immigrants from high- incidence areas, drug users—further compounds the problem (6, 7).

Against this backdrop, the Pan Ameri-can Health Organization (PAHO), with the support of the United States Agency for International Development (USAID) and local TB programs, developed an ini-tiative to improve TB control in urban areas in the Region of the Americas. The “Framework for TB Control in Large Cit-ies of Latin America and the Caribbean” (FTCLAC; 8) provides a comprehensive and multi-sectorial approach to TB con-trol in urban areas, incorporating multi-ple actors and addressing key social determinants that perpetuate the dis-ease, while taking into account the local health system structure (8).

Given the scarce information available on the practices of urban hospitals re-garding patients with TB, a key compo-nent of the framework was to conduct a survey to address the gap. To this end, this study presents the findings from the FTCLAC hospital survey, with the aim of generating actionable insights that can be used to improve TB control activities at the hospital level across cities in Latin America.

MATERIALS AND METHODS

A descriptive study with analytical components was conducted on the basis of a multi-city, cross-sectional hospital survey carried out in 2013–2015. A hospi-tal was defined as a health care institu-tion with in-patient care (9).

Study instrument

The survey was developed by PAHO and consisted of three main sections: hospital identification, hospital charac-teristics, and activities related to TB con-trol, for a total of 65 questions. In each institution, the tool was administered by up to two trained pollsters who fol-lowed a guidance document to ensure standardization. A pilot survey had been carried out at the San José del Cal-lao Hospital, in Callao, Peru, in 2013. The survey was applied in hospitals of

selected cities that were willing to par-ticipate and share results: Asunción (Paraguay), Bogotá (Colombia), Guarul-hos (Brazil), Guatemala City (Guate-mala), and Lima (Peru).

Study sample

The sampling was purposive, aiming to use a total population technique based on information provided by local health authorities. Importantly, the selection criteria for hospitals in each city varied according to the local context. In Guate-mala City, the survey was administered in hospitals belonging to a “municipal health district” that included the neigh-boring area of Mixco; only hospitals of median or higher complexity (HMHC), defined as those having other types of medical services beyond general medi-cine, were surveyed in this city. In metro-politan Lima, only public, HMHC were covered. In Asunción, the target was the metropolitan area, with only public insti-tutions participating. In Bogotá, public and private HMHC were surveyed. Lastly, in Guarulhos all hospitals were included.

The survey was conducted with the consent of national, local, and hospital authorities. Data was collected through interviews with administrative and clinical personnel at each participating hospital. Since the survey gathered ag-gregated information at the hospital level and no individual patient data whatsoever, ethical approval was not required.

Data analysis

Survey data was compiled and ana-lyzed by PAHO. Descriptive statistics with some analytical components were conducted, and observations with miss-ing data for the most relevant questions were not included in the analysis. Also, given that information from private hos-pitals was not available in some cities, the data was disaggregated by public/pri-vate hospitals to allow for more accurate comparisons across cities. When assess-ing statistical differences between cate-gorical variables, a Chi-squared or Fisher exact test was used. The Mantel–Haenszel test for Risk Ratios (RR) was used to as-sess the magnitude of association and ad-just for confounders, when necessary. P-values < 0.05 were considered statisti-cally significant. The information was

analyzed using Stata® 13.1 (StataCorp LP, College Station, Texas, United States).

RESULTS

Initially, 161 hospitals were invited to participate. All selected cities had a 100% response rate, except Guatemala City with 66%. Consequently, only 145 hospi-tals were surveyed. Moreover, given the volume of data missing from some hos-pitals surveyed in Guatemala City, two public and nine private hospitals were removed from the analysis. Likewise, two health care institutions in Bogotá and four in Asunción were not analyzed because they did not meet the inclusion criteria. Thus, a total of 128 institutions were included in the final analysis (Table 1). Hospitals were classified by size (based on the number of beds using terciles as cutoff points), public or pri-vate, and general or specialized. For Asunción and Lima, no data was col-lected from private hospitals.

Across all cities, most public hospi-tals had a TB program, although in Guarulhos the number was low, just 20.0% (Table 2). With respect to care standards for people with active TB (PWAT), most hospitals used guidelines that followed national recommenda-tions (96.0%). Notably, public hospitals in Guarulhos and private hospitals in Guatemala City were not subject to su-pervision by the respective TB program. With regard to TB contact tracing (TBCT), private institutions in Bogotá and public hospitals in Guarulhos did not conduct this activity (Table 2). Nota-bly, there was a statistically significant correlation between hospital size and TBCT, with larger institutions being less likely to carry out tracing (P < 0.05). Lastly, most hospitals notified the na-tional or local TB program once a pa-tient was diagnosed with TB, with an overall average of 94.5%.

Overall, most hospitals conducted acid-fast bacilli smears (AFB), with an average of 91.3% (Table 3). In addition, among the hospitals that performed AFB, 94.0% conducted a quality control test. With respect to TB culture and drug sus-ceptibility testing (DST), 44.4% and 6.8% of hospitals offered these, respectively; the Xpert®MTB/RIF assay (Xpert), which not only diagnoses TB, but also tests for resistance to Rifampicin, was included in the latter category. Hospitals in Guarul-hos and public hospitals in Bogotá did

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Moreno et al. • Hospital-based TB control activities in five cities Original research

not conduct DST. Of note, there was no available information on cultures and DST for private hospitals in Guate-mala City.

In relation to TB diagnosis, most hos-pitals used bacteriological tests (Table 3), with an overall average of 97%. In gen-eral terms, hospitals in Bogotá and Lima always confirmed TB diagnosis using a combination of symptoms, bacteriology, and chest radiography.

Once a patient was diagnosed with TB, the case management varied significantly across cities. In Asunción, for example, 87.5% of hospitals started and continued treating patients on an ambulatory basis, whereas in Guarulhos neither public nor private hospitals did so (Table 4). When hospitals offered ambulatory TB treatment, on average 68.7% of them

conducted Directly-Observed Therapy (DOT) (1st and 2nd phase). Notably, TB drugs were offered free of charge almost universally (97.1%), the exception being the private sector in Guatemala City (only 33.3%).

Besides providing ambulatory TB treatment, most hospitals (84.4%) also referred PWAT to other institutions to continue therapy (Table 4). How-ever, confirmation of successful referral only took place in 20.0% – 67.7% of hospitals, for a total average of 52.8%. Likewise, most hospitals (87.5%) offered TB inpatient care depend-ing on the patient’s clinical condi-tion. Regarding multidrug-resistant TB (MDR-TB), 95.8% of all hospitals re-quested DST when drug resistance was suspected.

It was found that, on average, 69.5% of hospitals treated people living with HIV (PLHIV) and co-infected with TB (Table 4). In these hospitals, TB screening in PLHIV was nearly universal and usu-ally based on symptoms (99%); the per-centage of patients initially diagnosed with active TB and then screened for HIV was also high, at 95%. In addition, the provision of Isoniazid preventive ther-apy (IPT) in PLHIV without active TB was found to be low across cities, with an average of 41.4%. Lima was a notable ex-ception at 78.6%. For PLHIV with active TB, the provision of antiretroviral ther-apy (ART), overall, was 55.1%. Guarul-hos had a figure of 0 since that city’s ambulatory ART was not provided in hospitals, but rather in HIV-specialized clinics.

TABLE 1. Characteristics of hospitals selected for a study on tuberculosis (TB) control activities in five cities in Latin America, 2013–2015

CharacteristicsGuatemala City Bogotá Guarulhos Lima Asunción Total

n % n % n % n % n % n %

Financing source Public 10 47.6 20 29.4 5 38.5 17 100.0 16 100.0 68 53.1Private 11 52.4 41 68.3 8 61.5 0 0.0 0 0.0 60 46.9

Hospital type General 7 33.3 49 80.3 10 76.9 11 64.7 12 75.0 89 69.5Specialized 14 66.7 12 19.7 3 23.1 6 35.3 4 25.0 39 30.5

Size Small (< 70 beds) 13 61.9 15 24.6 3 23.1 2 11.8 8 50.0 41 32.0Medium (70–195 beds) 4 19.1 21 34.4 7 53.9 4 23.5 2 12.5 38 29.7Large (≥ 195 beds) 4 19.1 21 34.4 3 23.1 8 47.1 3 18.8 39 30.5No data 0 0.0 4 6.6 0 0.0 3 17.7 3 18.7 10 7.8

Total 21 100.0 61 100.0 13 100.0 17 100.0 16 100.0 128 100.0

Source: Prepared by the authors based on the study data.

TABLE 2. Organization, guidelines, and supervision of tuberculosis (TB) activities in selected hospitals in five cities in Latin America, 2013–2015

Variable

Guatemala City Bogotá Guarulhos Lima Asunción

TotalPublic Private Public Private Public Private Public Public

n % n % n % n % n % n % n % n % n %

Number of hospitals 10 100.0 11 100.0 20 100.0 41 100.0 5 100.0 8 100.0 17 100.0 16 100.0 128 100.0

Presence of TB program 8 80.0 1a 9.1 20 100.0 40 97.6 1 20.0 2 25.0 16 94.1 14 87.5 102 79.7

Use of national TB diagnosis and treatment guidelines

10 100.0 4a,b 57.1 20 100.0 40 97.6 4 80.0 8 100.0 17 100.0 16 100.0 119 96.0

Hospital supervision by the national/local TB program

6 60.0 0a 0.0 19 95.0 37 90.2 0 0.0 3 37.5 16 94.1 14 87.5 95 74.2

TB contact tracing 4 40.0 3c 33.3 8 40.0 0a 0.0 0 0.0 2c 28.6 10 58.8 15 93.7 42 33.6

Notification of TB cases to national/local TB program

9 90.9 7 63.6 20 100.0 41 100.0 5 100.0 8 100.0 16 94.1 15 93.7 121 94.5

Source: Prepared by the authors based on the study data.a P < 0.05 when compared to the public sector of the same city. b Information available for 7 hospitals.c Information for private Guatemala City and Guarulhos available for 9 and 7 hospitals, respectively.

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Original research Moreno et al. • Hospital-based TB control activities in five cities

In relation to TB infection control measures in health care settings, 90.5% of hospitals had an infection control committee, although Asunción had a low number, at 56.2% (Table 5). In addi-tion, on average, only 34.1% of hospi-tals separated presumptive PWAT while in waiting rooms. Furthermore, only an average of 43.7% of hospitals conducted TB screening for clinical staff. Of note, public hospitals in Guate-mala City, Guarulhos, and Lima had a high proportion of clinical staff with ac-tive TB. However, this difference was only statistically significant for Lima after comparing public hospitals among each other and either adjusting for hos-pital size (RR 2.54; 95% confidence in-terval [95%CI] = 1.57–4.12) or the presence of TB screening (RR 3.17; 95% CI = 1.72–5.82). In addition, despite the importance of proper ventilation for preventing TB transmission in health care settings, most hospitals did not provide enough, accurate information on this topic. Therefore, it was not pos-sible to analyze nor include this vari-able in the study.

DISCUSSION

Despite the heterogeneous sample, this study shed light on a subject for which there is little information in the Region. Given the large amount of

information obtained in the results, only the most relevant outcomes were discussed.

Overall, most hospitals in the study used bacteriology coupled with symp-toms as the main tools to diagnose TB—in line with current standards (10). In addition, AFBs usually underwent a quality control process. This is of particu-lar importance given that high quality- assured bacteriology is a priority in TB control (11). Another trend across hospi-tals was the scarce verification of suc-cessful referral of PWAT. This is of particular concern since some lost-to-fol-low-up patients will not receive early treatment or any treatment at all, making clinical outcomes poorer and perpetuat-ing the transmission of both TB and MDR-TB (12). In addition, hospitals rarely carried out TBCT. As explained in the results section, this is probably re-lated to the institution’s size, which in turn is a proxy of a hospital’s complexity. Frequently, more complex health care in-stitutions, such as those in Bogotá, Lima, and Guatemala City leave TBCT to pub-lic health authorities and/or to smaller, more primary health care focused hospi-tals like those in Asunción. Despite this, it is imperative that hospitals not offer-ing TBCT do their utmost to ensure that patients are directed to facilities capable of comprehensive TB management and TBCT.

Regarding city trends, in Guatemala City a low proportion of both public and private hospitals conducted DOT. More-over, several hospitals in the private sector were not willing to disclose infor-mation, and some charged for TB medi-cation. Against this backdrop, closer surveillance of hospitals by the Guate-malan TB program and greater private hospital engagement are relevant factors to tackling TB transmission. With respect to Bogotá, the implementation of DOT in the private sector was considerably be-low the goal of 100% coverage, leaving room for improvement. It has to be clari-fied that many hospitals in Bogotá do not conduct TBCT, as this is a duty assigned to local public health authorities (13). Meanwhile, the high levels of ambula-tory TB treatment and TBCT in Asunción are likely due to the public nature of the surveyed institutions, coupled with the fact that many of the hospitals were gen-eral and possibly primary health care ori-ented, as previously discussed.

In addition, it was found that health care workers in Lima had a higher risk of TB infection compared to other cities, a finding that is supported by other re-ports (14, 15). This may be partially due to the high local TB burden, among the highest in the Region (3).

In this study, many hospitals con-ducted AFB and diagnosed PWAT, but only a smaller proportion provided

TABLE 3. Availability of bacteriological tests and criteria for diagnosing tuberculosis (TB) in selected hospitals in five cities in Latin America, 2013–2015

Variable

Guatemala City Bogotá Guarulhos Lima Asunción

TotalPublic Private Public Private Public Private Public Public

n % n % n % n % n % n % n % n % n %

Number of hospitals 10 100.0 11 100.0 20 100.0 41 100.0 5 100.0 8 100.0 17 100.0 16 100.0 128 100.0Availability of acid-fast

bacilli test (AFB) 9 90.0 7a 70.0 19 95.0 39 95.1 4 80.0 6 75.0 17 100.0 15 39.7 116 91.3

AFB quality control process 9 100.0 6 85.7 19 100.0 38 97.4 4 100.0 5 85.3 14 82.3 14 93.3 109 94.0

Availability of TB culture 3 30.0 — — 12 60.0 20 48.8 3 60.0 2 25.0 9 52.9 3 18.7 52 44.4

Availability of drug susceptibility tests, including Xpert

3 30.0 — — 0 0.0 3 7.3 0 0.0 0 0.0 1 5.9 1 6.2 8 6.8

Diagnosis based on: Symptoms 8 80.0 7 63.6 20 100.0 41 100.0 5 100.0 7 87.5 17 100.0 10 62.5 115 89.8 Bacteriologyb 10 100.0 10 90.9 20 100.0 41 100.0 5 100.0 6 75.0 17 100.0 15 93.7 124 97.0 Chest X-ray 7 70.0 8 72.7 20 100.0 40 97.5 4 80.0 7 87.5 17 100.0 9 56.2 112 87.5 Other testsc 4 40.0 1 9.1 3 15.0 12 29.3 0 0.0 3 37.5 4 23.5 1 6.2 28 21.9

Source: Prepared by the authors based on the study data.a Information available for 10 hospitals.b Bacteriology includes acid-fast bacilli test, culture, and Xpert. c Includes biopsy, polymerase chain reaction (PCR), purified protein derivative (PPD), and computed tomography (CT scan).

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Moreno et al. • Hospital-based TB control activities in five cities Original research

ambulatory TB treatment since most hospitals referred patients to other insti-tutions. This appeared to be the case, particularly in Brazil, where on many occasions hospitals are the primary place in which TB is detected, but treatment is provided in primary health care facilities (16, 17). Despite this, public hospitals in Guarulhos and private ones in Guate-mala City were not subject to supervi-sion by the local TB program; were they, oversight could contribute to improve-ments in the quality of TB diagnosis and completion of referrals.

In addition, one of the key targets in TB control is the adequate management of TB/HIV (11). Surprisingly, IPT, which decreases the incidence of active TB in PLHIV (18, 19), was rarely implemented in most of the hospitals included in the study. Therefore, revision of institutional policies should be conducted to include TB prophylaxis as a regular practice in PLHIV without active TB. At the same

time, it is worth noting that hospitals in our study reported higher ART coverage than that described by Regional reports (3). This could be due to either higher ART availability in urban areas com-pared to national averages, or to a higher provision of treatment in hospitals that care for TB/HIV coinfected patients.

Another important aspect of TB con-trol is preventing its nosocomial trans-mission (20). It was found that relatively inexpensive TB infection control mea-sures—use of surgical mask by patients, separation of presumptive PWAT in waiting rooms (20)—were not univer-sally implemented. Additionally, most of the city hospitals conducted limited TB screening among their staff, despite that working in a health care facility is a risk factor for developing TB and MDR-TB (21). Consequently, stricter TB infection control measures, in coordination with hospital infection control committees, should be put in place.

Limitations

This study had limitations such as rep-resentativeness—the outcomes for Bo-gotá, Guatemala City, and Lima reflect only the actions taken by hospitals of higher complexity, whereas in Asunción and Guarulhos all complexity levels were surveyed. In addition, the results from Guatemala City, especially those from the private sector, are likely not rep-resentative given the number of excluded hospitals. This limitation was secondary to (i) their reluctance to participate in the survey and (ii) the large quantity of missing information for those that partic-ipated. Furthermore, the unwillingness of the private sector to disclose informa-tion was noteworthy.

Conclusion

This study found that hospitals in the surveyed cities are implementing, to

TABLE 4. Hospital management of patients with tuberculosis (TB) among selected hospitals in five cities in Latin America, 2013–2015

Variable

Guatemala City Bogotá Guarulhos Lima Asunción

TotalPublic Private Public Private Public Private Public Public

n % n % n % n % n % n % n % n % n %

Number of hospitals 10 100.0 11 100.0 20 100.0 41 100.0 5 100.0 8 100.0 17 100.0 16 100.0 128 100.0Hospitals with full ambulatory

TB treatmenta 4 40.0 2 18.2 11 55.0 10b 24.4 0 0.0 0 0.0 9 52.9 14 87.5 50 39.1

Hospitals implementing both phases of directly-observed therapy

1 25.0 1 50.0 8c 80.0 5 50.0 NAd NAd NAd NAd 7 77.8 11e 84.6 33 68.7

Free TB medication 10 100.0 1b,f 33.3 20 100.0 41 100.0 NAd NAd NAd NAd 17 100.0 13g 92.9 102 97.1Hospital refers patients to other

facility for continuous treatmenta 7 70.0 11 100.0 19 95.0 41 100.0 5 100.0 4 50.0 15 88.2 6 37.5 108 84.4

Verification of successful referral 4 57.1 5 45.4 11 57.9 24h 60.0 1 20.0 1 25.0 7 46.7 4 67.7 57 52.8Hospitalization if necessarya 6 60.0 4 36.4 19 95.0 40 97.6 5 100.0 6 75.0 16 94.1 16 100.0 112 87.5Hospital requests drug

susceptibility test for patients suspected of having multidrug-resistant TB

7i 87.5 4i 100.0 18i 100.0 34i 100.0 — — — — 15 88.2 13i 92.9 91 95.8

Hospital treats HIV/TB coinfected patients 8 80.0 2b 18.2 14 70.0 27 65.9 5 100.0 5 62.5 14 82.4 14 87.5 89 69.5

Provision of Isoniazid preventive therapy in people living with HIV (PLHIV) without active TB

4 50.0 0 0.0 6 42.8 10 37.0 1j 33.3 0 0.0 11 78.6 4 28.6 36 41.4

Provision of antiretroviral therapy in PLHIV with active TB 5 62.5 1 50.0 7 50.0 19 70.4 0 0.0 0 0.0 12 85.7 5 35.7 49 55.1

Source: Prepared by the authors based on the study data.a These activities can overlap.b P < 0.05 when compared to the public sector of the same city.c The public sector in Bogotá had available information for 10 hospitals.d Not applicable e The public sector in Asunción had available information for 13 hospitals.f The private sector of Guatemala City had available information for 3 hospitals.g Asunción had available information for 14 hospitals.h Information available for 40 hospitals.I Information for public and private Guatemala, public and private Bogotá and Asunción available for 8, 4, 18, 34, and 14 hospitals, respectivelyj Available information for 3 hospitals.

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Original research Moreno et al. • Hospital-based TB control activities in five cities

various degrees, TB control activities. Many of these activities, however, need to be completed and/or enhanced, in-cluding supervision and standardization of TB diagnosis and treatment, TBCT, TB prophylaxis in PLHIV, and TB infection control measures at the institutional level. These results underscore the need to foster partnerships between the pri-vate and public sectors, as well as to co-ordinate among stakeholders and levels of care, especially with primary health care services. Local TB programs and

health authorities may use these results to improve the quality of TB-related ac-tivities in the selected cities and in other similar settings in Latin America.

Acknowledgements. This study was possible thanks to the collaboration of the national and local tuberculosis pro-gram of the countries in which the sur-vey was conducted.

Funding. The study was funded by the United States Agency for International

Development (Washington, DC, United States; Grant 002140). This institution did not have any role in study design, data collection, data analysis, or decision to publish.

Conflicts of interest: None declared.

Disclaimer. Authors hold sole respon-sibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.

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TABLE 5. Preventive measures and detection of tuberculosis (TB) transmission in hospital settings in five cities in Latin America, 2013–2015

Variable

Guatemala City Bogotá Guarulhos Lima Asunción

TotalPublic Private Public Private Public Private Public Public

n % n % n % n % n % n % n % n % n %

Number of hospitals 10 100.0 11 100.0 20 100.0 41 100.0 5 100.0 8 100.0 17 100.0 16 100.0 128 100.0Hospital has an infection

control committee 9 90.0 7a 70.0 20 100.0 40 97.6 5 100.0 8 100.0 17 100.0 9 56.2 115 90.5

Includes TB control activities 8 88.9 4 57.1 16 80.0 34 85.0 4 80.0 7 87.5 12 70.6 6 66.6 91 79.3

Separation of presumptive people with active TB in waiting rooms

4 40.0 5b 55.5 1 5.0 16b 40.0 1 20.0 3 37.5 6 35.3 6b 42.9 42 34.1

Patients use surgical masks 9c 100.0 6c 85.7 9d 45.0 31 75.6 5 100.0 8 100.0 17 100.0 13 81.2 98 79.7

Staff uses N95 masks 8e 88.9 4e 66.7 18 90.0 41 100.0 5 100.0 8 100.0 15 88.2 6e 42.9 105 87.5Hospital staff screened

for TB 2 20.0 7d 63.6 6 30.0 16 39.0 2 40.0 2 25.0 13 76.5 8 50.0 56 43.7

Hospital had cases of clinical staff with TB during the last year

4 40.0 1 9.1 5f 26.3 10 24.4 2 40.0 0f 0.0 13f,g 81.2 1 6.2 36 29.0

Source: Prepared by the authors based on the study data.a Available information for 10 hospitals.b Information for private Guatemala City, private Bogotá and Asunción available for 9, 40, and 14 hospitals, respectively.c Information for public and private Guatemala City available for 9 and 7 hospitals, respectively.d P < 0.05 when compared to public sector of the same city.e Information for public and private Guatemala City, and for Asunción available for 9, 6, and 14 hospitals, respectively f Information for public Bogotá, private Guarulhos and Lima available for 19, 6, and 16 hospitals, respectively.g P < 0.05 when compared to other public hospitals in other cities and after adjusting for possible confounders such as hospital size or the presence of a TB screening program.

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Moreno et al. • Hospital-based TB control activities in five cities Original research

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Manuscript received on 9 October 2016. Accepted for publication on 16 October 2016.

RESUMEN Objetivo. Generar información utilizable para mejorar el control de la tuberculosis en las zonas urbanas describiendo las actividades hospitalarias de control de la tuber-culosis de cinco ciudades de América Latina.Métodos. Se realizó un estudio descriptivo de las actividades hospitalarias de con-trol de la tuberculosis mediante una encuesta transversal formulada por la Organización Panamericana de la Salud y administrada entre el 2013 y el 2015 en Ciudad de Guatemala (Guatemala), Guarulhos (Brasil), Bogotá (Colombia), Lima (Perú) y Asunción (Paraguay). Los datos fueron analizados con la prueba de la ji al cuadrado, la prueba exacta de Fisher y la prueba de asociación de Mantel-Haenszel de las razones de riesgos, según fuera necesario (P < 0,05).Resultados. Pese a la variación observada entre las ciudades, la mayor parte de los hospitales (91,3 %) realizan frotis de bacilos acidorresistentes para diagnosticar la tuberculosis y disponen de un proceso de control de la calidad (94,0 %), siguen las directrices nacionales respecto de la tuberculosis (95 %) y notifican los casos a las auto-ridades de salud respectivas (96 %). Además, casi todos ofrecen tratamiento antituber-culoso gratuito (97,1 %). Sin embargo, solo el 74,2 % de los hospitales está supervisado por el programa nacional o local contra la tuberculosis; el 52,8 % hace el seguimiento de la evolución de los pacientes derivados; y el 39,1 % ofrece tratamiento antitubercu-loso plenamente ambulatorio a los pacientes, del cual el 68,7 % corresponde al tratam-iento bajo observación directa.Conclusiones. En el estudio se ponen de relieve las fortalezas y las debilidades de aspectos específicos de las actividades hospitalarias de control de la tuberculosis, así como la importancia y la complejidad que reviste coordinar los esfuerzos entre los hospitales privados y públicos y los diversos interesados directos. Los programas locales contra la tuberculosis y las autoridades de salud deben aprovechar estos resul-tados para mejorar la calidad de las actividades hospitalarias relacionadas con la tuberculosis en entornos similares.

Palabras clave Tuberculosis; servicios hospitalarios; ciudades; Brasil; Colombia; Guatemala; Paraguay; Perú; América Latina.

Actividades hospitalarias de control de la tuberculosis

en cinco ciudades de América Latina

8 Rev Panam Salud Publica 41, 2017

Original research Moreno et al. • Hospital-based TB control activities in five cities

Palavras-chave Tuberculose; serviços hospitalares; cidades; Brasil; Colombia; Guatemala; Paraguay; Perú; América Latina.

Objetivo. Originar insights proativos para melhorar o controle da tuberculose (TB) em áreas urbanas descrevendo as atividades de controle da TB em hospitais em cinco cidades na América Latina.Métodos. Estudo descritivo das atividades de controle da TB em hospitais realizado em 2013–2015 com base em pesquisa transversal concebida pela Organização Pan-Americana da Saúde e conduzida na Cidade da Guatemala (Guatemala), Guarulhos (Brasil), Bogotá (Colômbia), Lima (Peru) e Assunção (Paraguai). Os dados foram analisados com o uso do teste qui-quadrado, teste exato de Fisher e teste de Mantel–Haenszel para razões de risco, conforme necessário (P < 0,05).Resultados. Apesar de ter existido variação entre as cidades, a maioria dos hospitais (91,3%) realizou o teste de esfregaço de bacilos acidorresistentes para o diagnóstico de TB e dispunha de um processo de controle de qualidade (94,0%), seguiu os protocolos nacionais de TB (95%) e notificou casos de TB aos órgãos sanitários competentes (96%). Além disso, o tratamento de TB foi proporcionado gratuitamente quase como um todo (97,1%). Porém, somente 74,2% dos hospitais receberam supervisão dos programas locais ou nacionais de combate à TB; 52,8% acompanharam os desfechos dos encamin-hamentos e 39,1% ofereceram tratamento de TB ambulatorial completo, sendo que 68,7% usaram o tratamento diretamente observado.Conclusões. O estudo destacou os pontos fortes e os pontos fracos em áreas específi-cas das atividades de controle da TB em hospitais e ressaltou a importância e a com-plexidade de coordenar esforços entre hospitais públicos e privados e as diversas partes envolvidas. Os programas locais de combate à TB e as autoridades sanitárias devem se basear nestes resultados para melhorar a qualidade das ações relacionadas à TB nos hospitais em condições semelhantes.

RESUMO

Atividades de controle da tuberculose em hospitais

em cinco cidades da América Latina